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Covid-19 Questionnaire

Patient Disclosures

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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

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Demographic Information

Patient Information

Section Two

Insurance Information

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

General Insurance Information

School Information

Primary Insurance Information

Secondary Insurance Information

Consent

Consent for Services

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Medical History

Medical History

Have you had or do you currently have...

Have you had or do you currently have...

Medication & Allergies

Are you now taking

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Are you allergic to, or had a reaction to:

Please list any other medication or antibiotic you are allergic to

Please list any allergies other than drug allergies

This section is for women only

Dental History

Conclusion

In case of emergency

Verification

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